Lance could choose aggressive surgery

ESPN.com—March 24, 2009

Lance Armstrong is far from typical. His intense training regimens, legendary cycling success and ability to conquer cancer all combine to place him outside the realm of the common man. That was until Monday, when Armstrong suffered a very common injury during a bike race in Spain.

Armstrong sustained a fractured collarbone, or clavicle, when he went over the top of his handlebars as part of a multi-cyclist collision near the end of the opening stage of the Vuelta a Castilla y Leon. Clavicle fractures make up roughly 5 percent of all fractures in the general population, and of those, fractures in the middle third of the bone (where Armstrong is reported to have suffered his injury) comprise 85 percent. These fractures are typically caused by a fall onto the arm or shoulder, which, with cyclists, usually results from going over the handlebars, but can also result from a fall on the side.

Armstrong is headed back to the United States, where he plans to undergo surgery to stabilize the fracture, leaving everyone wondering whether this setback will prevent him from competing in the upcoming Tour de France in July. In order to appreciate what Armstrong faces in trying to get back to competition, it helps to understand the consequences of his injury.

The clavicle is the bone that connects the sternum (breastbone) to the scapula (shoulder blade). It has a unique shape, like a crank shaft, and it is that shape that contributes to its critical function as part of the complex shoulder girdle. The clavicle, which elevates and rotates, helps guide arm motion while its ligamentous connections to the shoulder blade offer stability to the limb, as well. Consequently, an injury to the clavicle threatens the mechanics of the entire upper extremity. A broken bone (Armstrong's injury) or ligament injury (often referred to as a shoulder separation) can lead to chronic problems if not properly addressed.

Historically, the most common course of treatment for a clean non-displaced fracture (meaning the bony ends are not shattered and remain in good alignment) has been non-operative. The patient wears a sling, keeps the arm relatively immobile initially and allows the bone to heal over a period of approximately six weeks. In cases in which the bone is fragmented, or the fracture is displaced (the ends are out of alignment), surgery has traditionally been the best option.

But over the past decade, there has been a shift toward a more aggressive treatment, according to Dr. Frank Cordasco, an orthopedic surgeon at Hospital for Special Surgery in New York. Cordasco, who has treated a number of cyclists ranging from recreational to competitive and is a cyclist himself, reports that the trend toward more aggressive surgical treatment, for athletes in particular, emanated from Europe.

One study published in the British Journal of Sports Medicine in 2003 examined high-performance athletes with minimally displaced fractures who underwent surgery using titanium nails to address the break. These athletes were able to return to training in an average of six days and to competition within an average of 17 days, far quicker than would be possible without surgery.

Cordasco adds the surgery for a more substantial fracture may require a plate and screws. Although this surgery is more complex, it provides a much better outcome in the case of more severely displaced fractures. With the evolution of surgical technology, these plates are small enough that they rarely require subsequent removal, originally a side effect of this type of surgery. Cordasco emphasizes that without knowing the specifics of Armstrong's particular injury, it is impossible to state with any certainty which surgical approach he will undergo.